Telehealth strategies in the care of people with chronic kidney disease: integrative review

Objective: to evaluate the evidence about telehealth strategies in caring for people with chronic kidney disease. Method: integrative literature review. The search for primary studies was carried out in six databases: PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, LILACS, and Scopus. The sample consisted of 48 articles published between 2000 and 2021. The telehealth strategy was applied by a multidisciplinary team of doctors, nurses, pharmacists, nutritionis, and social workers. The type of study, country, strategy applied, setting, population, and professional were extracted from the articles. The studies were selected by reading the title and abstract (phase 1) and then reading them in full (phase 2), categorizing them by telehealth strategy. The results were summarized descriptively and the studies were classified according to their level of evidence. Results: the home was the most representative in dialysis and conservative treatment. Six categories of telehealth strategies were identified: remote monitoring devices, teleconsultation, digital platforms, apps, multimodality strategies, and telephone contact. Conclusion: using these strategies for the care of people with chronic kidney disease presents different forms and implementations, being feasible for the renal population at any stage of the disease and applicable by different health professionals with an emphasis on the home environment. The evidence shows that telehealth favors lower cost, accessibility to remote locations, and better monitoring of dialysis with positive resul in symptom control, risk reduction, and patient training.


Introduction
Chronic kidney disease (CKD) is a complex public health problem and affects around 8% to 16% of the world's population, as well as being associated with high cardiovascular risk and death (1) .It is characterized by slow, progressive, and irreversible changes in kidney function or structure, the main causes of which are arterial hypertension, Diabetes Mellitus, and glomerulonephritis, among others (2) .According to its progression -evidenced by the drop in glomerular filtration rate -CKD is classified into five stages that require specific treatment and monitoring depending on the degree of kidney damage.The fifth and final stage is marked by the terminal phase of chronic renal failure, in which Renal Replacement Therapies (RRT) such as Hemodialysis (HD), Peritoneal Dialysis (PD), and/or transplantation are necessary (1)(2) .
A multi-professional approach is essential in the optimized management of CKD, in terms of dietary control, pharmacotherapy, adjusting risk factors, and promoting self-care.Given its complexity, health professionals must be aligned with the tools available for effective interventions in the care of these patients, including the possibilities offered by digital technology (3) .
In this sense, Telehealth (TH), which covers the most diverse categories of remote care, presents itself as a viable and safe strategy to support the needs of chronic kidney patients (4)(5) .TH involves providing and promoting long-distance clinical care, health education for patients and professionals, public health, and health administration (5)(6) .Thus, it is understood that apps of telehealth include: digital media, short message service, mobile apps, interactive voice response, videoconferencing, asynchronous storage communication, routing, and wireless communication (3,6) .
Despite the expansion of telehealth during the COVID-19 pandemic, successful experiences before this period have shown the positive impact of telemedicine in the care of chronic conditions, such as Diabetes Mellitus (7)(8) .These results demonstrate the potential for the app of telemedicine in CKD, in the sense of leveraging multidisciplinary care in the area, breaking with traditional care methodologies, and fostering self-responsibility in those who live with this condition daily (5) .This could be strongly experienced during the pandemic when TH was widely used to maintain and provide care to users and comply with the rules restricting the movement of people needed to combat the pandemic.
However, the application of TH in clinical practice in Nephrology, although it has expanded, still presents obstacles and needs to be discussed from various aspectsclinical, ethical and normative (10) .In clinical practice, it is important to assess the effectiveness and cost-benefit of these technological practices compared to traditional care, as well as determine which technologies and how it is being applied by the various professionals in the multidisciplinary team who provide care to people with CKD.The path taken by TH in the field of Nephrology continues to expand, but it is essential to understand this process and how its players behave in an environment of atypical and increasingly digital resources (3) .Thus, telehealth in Nephrology has diverse approaches, in different contexts of CKD care and by any health professional (5) indicating the need to synthesize the evidence published in the area.Thus, this review aims to evaluate the evidence about telehealth strategies in caring for people with CKD.

Delimitation of the sample
The research problem -structured by the acronym PICO (P= people with CKD; I= telehealth; C= not Insufficiency" OR "Chronic Renal Insuff, Chronic" OR "Chronic Renal Failure" OR "ESRD" OR "Renal Failure, Chronic" OR "Renal Failure, Chronic" OR "Renal Failure, Chronic" OR "Renal Failure, Chronic" OR "Renal Failure, Chronic" OR "Renal Failure, Chronic" OR "Kidney Diseases, Chronic" OR "Chronic Renal Diseases, Chronic" OR "Kidney Diseases, Chronic" OR "Kidney Diseases, Chronic" OR "Kidney Diseases, Chronic" OR "Kidney Diseases, Chronic" OR "Kidney Diseases, Chronic" OR "Chronic Renal Diseases, Chronic" OR "Kidney Diseases, Chronic" OR "Chronic Renal Diseases, Chronic" OR "Chronic Renal Disease" OR "Disease, Chronic Renal" OR "Diseases, Chronic Renal" OR "Renal Disease, Chronic Renal" OR "Renal Disease, Chronic" OR "Renal Diseases, Chronic") AND ("Telemedicine Emergency Care" OR "Telemedicine" OR "Mobile Health" OR "Health, Mobile" OR "mHealth" OR "Telehealth" OR "eHealth" OR "Telemonitoring" OR "Teletherapy" OR "Telescreening, Medical").Similar search strategies were adopted for the other databases, with specific vocabularies according to the database, such as CINAHL Headings, Health Sciences Descriptors (DeCS), and Entry Terms for CINAHL, LILACS, and Embase, respectively.
The EndNote Web Basic (Clarivate Analytics ® ) software was used to identify and extract duplicates, and the Rayyan Qatar Computing Research Institute (Rayyan QCRI) platform (13) was used to select the studies in phase 1.

Selection criteria
The inclusion criteria were: interventions with telehealth, previously structured and applied by health professionals in adult patien with CKD -whether they are undergoing conservative treatment, dialysis, or transplantation, observational research -quasiexperimental, Clinical Trials (CT) with full text available in English, Spanish or Portuguese, with no restrictions on the period of publication.Consequently, the exclusion criteria were defined as research on the interest and usability of technologies, reviews, case studies, expert opinions, research protocols, hospital context, and different publications with the same intervention and sample.

Variables and data analysis
Two independent reviewers carried out the selection by title and abstract (phase 1) and the complete reading of the studies listed in the first selection (phase 2), followed by the extraction of data from those considered to be included.The same eligibility criteria were applied in both selection phases.An electronic spreadsheet (Microsoft Excel 2010 ® ) was used to gather the information of interest: authors, title, year of publication, study objective, country, methodological design, setting and population, telehealth strategy, results, and limitations reported.
The level of evidence was assessed according to the following classification: Level I (meta-analyses of randomized studies), Level II (experimental), Level III (quasi-experimental), Level IV (observational, cohort, case-control), Level V (systematic reviews of observational studies and qualitative studies), Level VI (single descriptive or qualitative study) and Level VII (opinions), with Levels I to IV being considered strong to moderate evidence (14) .
The included studies were organized categorically according to the telehealth strategies applied while the intervention and the information extracted were synthesized descriptively and presented in a summary table.

Results
The identification of potential studies through the databases retrieved 1,263 articles, of which 285 were duplicates.After selection by title and abstract based on the inclusion and exclusion criteria, 95 articles remained, which were read in full in a second stage that resulted in the inclusion of 48 publications in this review.This identification and selection process is illustrated in  Given the focus on telehealth strategies identified in the selected studies, the descriptive analysis resulted in six thematic categories: remote monitoring devices, teleconsultation, digital platforms, apps, multimodality strategies and telephone contact.Figure 2 brings together the main data extracted from the articles included by thematic category.More than 80% of the participants reported that the teleconsultation was as good as the face-to-face one, and 41% found it better.In addition, 81% of the patients declared the teleconsultation relevant, 58% reported new learning about their condition and 27% revealed changes in their perception of dialysis./Level VI To examine the effectiveness between nursing teleconsultations and faceto-face care in promoting behavioral changes.

Nursing teleconsultation and telephone follow-up.
Both groups showed similar behavioral changes.The IG § showed a better understanding of the severity of their disease, the need for self-care, and trust in nurses.The GC** showed a higher degree of behavioral change about self-monitoring./Level II Evaluate the usefulness of the automated † † PD RM ‡ system.Automated PD † † RM ‡ and telephone follow-up.
The number of night alarms, visits to the clinic, time spent and distances traveled were significantly lower in IG § .Patients reported ease of use of the RM ‡ system, and satisfaction with the level of interaction with the team and the timely resolution of technical problems.The intervention proved to be costeffective./Level VI To optimize blood pressure levels, involvement, and medication adherence.

Good Health Gateway digital portal and blood pressure check monitor (adherence feedback and pressure monitoring).
There was a statistically significant reduction in mean systolic and diastolic pressures of 6 mmHg and 3 mmHg, respectively./Level VI To evaluate the effects of telephonic care on physiological and psychological stressors.

Telephone contact
Telenursing by telephone monitoring, with face-to-face educational sessions.
The mean scores for physiological and psychosocial stressors were reduced in GI § after follow-up, with no changes in GC**.There were differences between the groups in terms of the mean post-test scores and the mean pre-and post-test differences for both stressors: physiological and psychosocial./Level II The compliance rate had a three-phase relationship with cardiovascular and all-cause hospitalizations.Low or very high compliance rates were associated with a higher risk of hospitalization.Patients with CKD † were associated with a higher risk of hospitalization, and dialysis patients had an increased risk when they had low adherence rates, compared to patients with normal kidney function or nondialysis CKD † ./ Level IV A priori, there were no significant differences between the groups for the hope scores.After the intervention, the level of hope in IG § was significantly higher, especially in those with telephone follow-up./Level II

Characterization of the included studies
(34)(35)(36)(37) .That said, there were a total of 39 different journals, of which seven presented more Among the countries with the highest number of publications, the United States (USA) obtained greater prominence, with 35.4% (17) of the productions on the theme, followed by Iran with four publications, the other seventeen countries presented between one and three studies.The second continent with the highest number of scientific records was the European (13/27/%), Latin America was represented by three publications, from Colombia (24,29) and Dominican Republic (38) .
Regarding the designs of the studies identified in this integrative review, clinical trials, randomized or not, total 17 (35.4%),descriptive observational studies comprised 13 (27.1%)productions, cohort studies represented nine articles (18.8%) and quasiexperimental, of the pre and post type, constituted eight (16.7%)publications.It was found that 37.5% (18) of the articles presented level II of evidence, followed by level IV with 22.9% (11).
The outcomes reported showed intense diversity among the studies, ranging from clinical indicators (hospitalization, peritonitis, emergencies, mortality), laboratory parameters (hemoglobin, phosphorus, albumin, calcium, cholesterol), blood pressure levels, to variables related to user satisfaction.Overall, behavioral changes, quality of life, and usability of the technological tools applied also constituted the spectrum of weighted outcomes, with costs evaluated in only five studies.
It is noteworthy that no included study showed unfavorable results to telehealth interventions, although fifteen of them reported no statistically significant differences between the groups investigated.Therefore, favorable implications were indicated in 32 studies, whose outcomes analyzed were positively inclined to remote assistance with hypothesis tests presenting statistical significance (p<0.05) in 24 investigations.

Remote monitoring devices
It included studies that worked with electronic devices capable of capturing biometric data of the user and sending it to the responsible team, which may be of immediate online transmission or not.Among them, the use of a wristwatch (21) , medication tray (17) , PD machine (22,29) and a monitoring station with a camera, microphone and monitor (31) were identified.

Teleconsultation
The teleconsultation category included studies that used videoconferencing as a service methodology, similarly called teleconference or video call.Its application occurred predominantly in the home environment (16,(45)(46)(47) and in clinics (19,(48)(49) , with the outpatient setting as the focus in only one study (50) .The target population of this strategy was individuals on hemodialysis who were part of four study treatments (16,46) , PD (47) and transplant recipients (45) .
The professionals with the greatest performance in this strategy were physicians (46,48) and nurses (16,47) who worked in two studies each, together with the nutritionist (50) .However, two publications did not specify which professional performed the care (44,49) .
As a result, teleconsultation was characterized as better or equally effective as face-to-face consultation by 80% of the participan, with the development of new skills and better perception of the therapy (19) .There was a positive impact on cost reduction (45)(46)(47) , waiting for time for care (46) and nutritional control of phosphorus levels (50) .Although teleconsultation did not present statistical superiority with renal transplant patients, there were no differences regarding the survival rate in this population (48) .

Digital platform
Digital platforms were characterized by all those studies that developed, tested, or applied patient care strategies through websites or online platforms hosted in the World Wide Web environment.Seven (14.6%) studies were classified from the USA (20,25,36,(51)(52) , Canada (34) , and Iran (53) , published between 2014 and 2020, except for 2015.There was a predominance of cross-sectional studies (25,34,52) and clinical trials (20,53) , representing five studies, followed by a quasi-experimental design (51) and cohort (36) .
The population included all renal groups, expressed by: transplanted (25) , hemodialysis (36,51) , peritoneal dialysis (52) , conservative (53), and mixed population (34) which included individuals on conservative and dialysis treatment.The home environment was the setting for four studies (25,34,36,52) , while two used the outpatient setting (20,53) and one was directed to the clinics (51) .Moreover, three productions did not identify the professionals working in the research (34,36,51) , and the other studies were developed by a social worker (25) , a multidisciplinary team (52) and a nurse, representing two productions (20,53) .
It was found that the use of the online platform can improve knowledge about dialysis therapies among users (20) and reduce the risk of complications in home hemodialysis (36) .In consonance, the use of a self-care support portal for home dialysis provided a reduction in the need to contact the clinic (34) , greater confidence and knowledge in performing the procedures in PD (52) and an improvement in glomerular filtration rates in those undergoing conservative treatment (53) .

Apps
The strategy in question was characterized by using apps directed to certain electronic devices, such as cell phones or tablets.Its use was predominantly in the home setting, to cover seven studies (15,32,(54)(55)(56)(57)(58) .Parallel to the above, only one publication mentioned the outpatient setting (58) in this category.Among the population present in this category were individuals under conservative treatment, PD and HD, expressed, respectively, in three, two, and one study.
Seven (14.6%) studies were identified that used apps as a remote service strategy, from the USA (55) , Ireland (57) , the United Kingdom (56) , China (32) , the United Arab Emirates (15) and Canada (54,58) .In the first instance, a pilot study was presented in 2009, which evaluated the impact of an app regarding the expansion of knowledge of renal patients (57) .In the second instance, there are three more studies carried out in 2015 (55) and 2016 (56,58) , followed by the years 2020 (15) and 2021 (54) .
Regarding the results, it is noted that the apps can increase the safety in the use of medications (54) and improve the intake of calories and proteins in patients under HD (15) .In addition to what has been discussed, there is an improvement in albumin, hemoglobin and calciumphosphorus levels in individuals under PD accompanied by an instant messaging device (32) .It is also noteworthy that those undergoing conservative treatments also benefited from the promotion of self-care with a reduction of blood pressure levels (58) , along with the verification of high rates of acceptability and satisfaction with the use of apps (55,57,59) .

Multimodality
The multimodality category frames the studies that used, with the same relevance, diversified and joint TH strategies.As an example, there are teleconsultation and text messages (24,26,38) , PD monitoring with telephone contact (28,60) , blood pressure monitoring with app (35) and blood pressure monitoring with an online platform for data collection (61) .Regarding the scenarios adopted, the home environment is presented in four studies (28,35,(60)(61) , the dialysis clinics in two (24,38) and the outpatient clinic in one (26) .
Among the sample population present in this category, PD patients stand out, which comprise four studies (28,38,60,62) .In the others, there were transplanted individuals (61) and under conservative treatment (26,35) , with the exclusion of patients on HD.The strategy under analysis obtained an overall calculation of seven articles (14.6%), of which two (28,60) present Italy as the country of origin.The others came from different countries in Latin America (24,38) , Europe (35,61) and Oceania (26) , however, none of them were from North America.
According to the results presented, it was understood that telephone follow-up and text messages were acceptable and feasible (26,28) , and there was a statistically significant reduction in the rates of peritonitis in a study that associated teleconsultation, telescreening and text messages (24) , as well as in the reduction of blood pressure when monitored remotely (63) .Nevertheless, in a study conducted during the 2020 pandemic, the indicators of peritonitis and hospitalizations did not present statistical differences when compared to patients who did not participate in TH (38) .

Telephone contact
This category refers to studies that applied only telephone contact as a form of remote monitoring, that is, videos or images were not applied.Thus, there were six studies (12.5%), five of them involved the home environment (23,27,33,(64)(65) , and another the outpatient setting (37) .Iran (23,27,64) , the USA (37,65) and China (33) were the countries that published the most in this modality.
It should be noted that no developing country was included in it.
Regarding the year of publication, it was verified that, except for 2016, all studies were published between 2015 and 2020, since in 2018 there were two publications (33,37) .
Regarding populations, it was found that patients on HD were in three studies (23,27,64) , while conservative treatment was only in one (35) , and the others addressed a mixed population (33,65) .
Telephone contact was the strategy of three studies developed as clinical trials (23,(64)(65) , two cohorts (33,37) and one quasi-experimental study (27) .The professional nurse was in four studies (23,27,33,64) with the use of telephone, the team in only one (65) , as well as the medical professional (37) .
The reported results indicated that HD patients under telephone monitoring presented lower physiological and psychosocial stressors (23) .They also showed that telephone contact by nurses provided the best results regarding physical exercise, stress, and responsibility (27) , so this method of care enabled greater adherence to consultations among individuals who lived far from clinical centers, with increased frequency and reduced cancellations (37) .In addition to the above, it was noted that the higher risk of hospitalization was verified among those with dialysis CKD when they did not participate in telephone monitoring (33) , and, ultimately, stress reduction was observed in renal transplant patien who practiced mindfulness by telephone (65) .

Discussion
Technological development has allowed the diffusion of different social interaction tools that can be applied in the health area, which is denoted by the various strategies found in the studies included in this review, grouped by similarity into six categories in which remote monitoring devices were the most frequent.The investigation supported by the American Society of Nephrology pointed out possibilities of interaction between patients and caregivers, intermediated by digital resources (6) , as in another survey that identified a wide diversity of these resources: virtual consultations, text messages, sending images via online questionnaires, optimized use of smartphones, among others (8) .
In addition to offering numerous possibilities, telehealth proved to be transversal and usable by the Nephrology team, although with greater applicability by individual professionals, such as nurses, pharmacists, nutritionists, and physicians.Although the area has historically been linked to devices and technological devices -dialysis machines -, the use of telehealth as a means of patient care from the resources already available gained visibility during the pandemic, when professionals and services had to adapt to social distancing (8,10) .
Regarding the places of publication, the predominance of studies from the United States and Europe evidences the potential interest, in these places, in the development of telehealth in Nephrology and the incorporation of information technology, mediating health care.In Latin America, there have been few publications restricted to remote monitoring in PD, although the published evaluation of telehealth in different regions of the globe has indicated an exponential increase in telephone consultations in Brazil, Ecuador, and Peru (9) .Moreover, it also indicates that in this region the use of telehealth is extremely low and is linked to the scarce financial resources, prejudice and resistance of health professionals.
However, the adequacy of services in the face of the incorporation of telehealth is inevitable and has gained greater evidence and robustness in the COVID-19 pandemic demonstrated by the high number of articles published between 2019 and 2021, twenty in total.
Similar results were found in another survey that, in the same way, verified the exponential and accelerated use of telehealth in all areas of health in this period (8) .
In Nephrology, the pandemic in a certain way forced its advancement and implementation, so that more discussions about the barriers and difficulties arose, while its benefits, although mostly intuitive, were confirmed (5) .
In this sense, it was remarkable the remote monitoring via electronic devices, telephone contact, and teleconsultation performed by doctors and nurses with people in HD and PD in the home environment, since twelve studies were thus characterized.In Singapore, the implementation of telehealth during the pandemic was essentially via teleconsultation of the doctor and nurse (10) .The use of smartphones and the availability of free videoconferencing platforms reinforced the practice of teleconsultation and remote monitoring of patients, demonstrating to be economically viable due to the reduction of visits to the treatment center, hospitalizations, and emergency care (8) .This result reinforces the use of telehealth in nephrology, especially for the remote monitoring of people who perform dialysis therapies at home.The complexity of the therapy and its risks demand from the patient a greater capacity for self-care and interaction with the health team, which is allowed by the use of communication technologies (5) .Moreover, a potential benefit of telehealth in Nephrology is the greater acceptance of home therapies where, despite the distance, access to professionals by the patient would be optimized (4) .
Finally, the results reported in the studies did not indicate the inferiority of telehealth compared to traditional care or non-acceptance, despite the different outcomes analyzed and the strategies used.In this sense, telehealth still lacks robust evidence about its clinical and economic effectiveness, acceptability, and viability from the perspective of the service, professional, and patient (5) .
It was also found that despite the accelerated use of telehealth designed by the pandemic, the theme has been the object of research in the field of nephrology for more than 20 years, proving to be feasible from the point of view of the user and provider.In addition, with the multiplicity of technological tools used in the care of CKD, it is perceived that guidelines are necessary to guide professional performance and the development of research that can unveil the effectiveness of technologies and improve access to them, to resolve regional inequities.
In addition, it was found that there are few and restricted studies involving renal transplant patients whose monitoring is outpatient and who, due to exposure to the risks of immunosuppression and polypharmacy, could greatly benefit from telehealth.
In this review, the comparability on the effectiveness between the various tools was not possible due to the diversity of methodological designs in the included studies, as well as the population studied and the outcomes evaluated by the study, the particularities pointed out in other publications (3)(4) .As limitations, we can mention the possibility of selection bias, which was controlled by the number of reviewers who selected the articles independently, the impossibility of access to the full text of four articles after exhausting the attempts, the absence of some data on the professional involved in the research, which did not prevent the possibility of characterization of the evidence listed.

Conclusion
The telehealth strategies used in the care of people applicable; O= clinical, laboratory and behavioral) -was: what evidence is available in the literature on telehealth Almeida OAE, Lima MEF, Santos WS, Silva BLM.strategies in the care of people with CKD?The controlled descriptors -Chronic Renal Failure, Dialysis, Transplantation and Telemedicine -were combined with the Boolean operators AND and OR in the PubMed/ MEDLINE, Web of Science, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Health Sciences Literature (LILACS) and Scopus databases through the journal portal of the Coordination for the Improvement of Higher Education Personnel (CAPES), in March 2021.The strategy applied to the PubMed and Scopus databases was created using the Medical Subject Headings (MeSH) in the following format: ("Kidney Failure, Chronic"[Mesh] OR "Kidney Failure, Chronic" OR "End-Stage Kidney Disease" OR "Disease, End-Stage Kidney" OR "End-Stage Kidney Disease" OR "End-Stage Renal Disease" OR "Chronic Renal Insufficiency" OR "End-Stage Renal Disease" OR "End-Stage Renal Disease" OR "End-Stage Renal Disease" OR "End-Stage Renal Disease" OR "End-Stage Renal Disease" OR "End-Stage Renal Disease" OR "End-Stage Renal Insufficiency" OR "End-Stage Renal Insufficiency" OR "End-Stage Renal

Figure 1 -
Figure 1 -Flowchart of the selection process for the studies included in the integrative review according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).Brasília, DF, Brazil, 2021 Kazawa, et al., 2020/ BMC Nursing/ Japan RCT*/Home-based/ Diabetics CKD †

*Figure 2 -
Figure 2 -Description of the characteristics of the studies included in the integrative review (n=48).Brasília, DF, Brazil, 2021 than one publication on the subject, three with scope in telemedicine (Journal of Medical Internet Research, Telemedicine and e-Health and Journal of Telemedicine and Telecare) and four in nephrology (Peritoneal Dialysis International, Journal of the American Society of Nephrology, Journal of Nephrology and Blood Purification).
with CKD have several forms and implementations identified in this study: remote monitoring devices, teleconsultation, digital platforms, apps, telephone contacts and strategies that associate two or more possibilities of telehealth, being feasible for the renal population in any phase of the disease and applicable by different health professionals with emphasis on the home environment.The application of these means of assistance has been going on for more than a decade and has gained emphasis with the restrictive measures of movement imposed by the COVID-19 pandemic.Telehealth care for people with CKD has been shown to reduce costs and improve clinical, laboratory and behavioral outcomes in patients, especially on dialysis.In addition, no study presented outcomes with a lower impact related to the use of telehealth strategies.This review pointed out an important research gap involving developing countries whose inequity of access, high indirect costs with dialysis treatment for access to more distant centers, and emergency care could be mitigated with the implementation of remote care by the care team.Similarly, the population of renal transplant recipients has been explored with telehealth in few and restricted publications.However, this study that analyzed the evidence in the literature showed that several firstworld countries have already advanced towards the incorporation of digital technologies, expanding the possibilities of providing effective care to the renal population by devices of common use and accessible to most people.Despite the existing barriers to the incorporation of these practices in health, the articulation of technologies available to users, such as smartphones, should be widely explored by health services to expand access to treatments and specialized professionals, as well as to